Provider Demographics
NPI:1043991318
Name:CISNEROS, ERICA STACEY
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:STACEY
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 W DEERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-9006
Mailing Address - Country:US
Mailing Address - Phone:209-587-7419
Mailing Address - Fax:
Practice Address - Street 1:460 W DEERWOOD LN
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-9006
Practice Address - Country:US
Practice Address - Phone:209-587-7419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program